Open versus Endovascular Abdominal Aortic Aneurysm Repair in the Australian Private Sector Over Twenty Years

Abstract

Purpose Over the past two decades, the proliferation of endovascular surgery has changed the approach to abdominal aortic aneurysm (AAA) repair. In Australia, close to two-thirds of surgical procedures are performed in the private healthcare system. We aimed to describe the trends in AAA repair in the Australian private sector throughout the early 21st century. Materials and Methods Medicare Benefits Schedule (MBS) statistics were accessed to determine the number of infrarenal open AAA repair (OAR) and endovascular AAA repair (EVAR) procedures performed between January 2000 and December 2019. Population data were extracted from the Australian Bureau of Statistics and used to calculate incidence per 100,000 population. Further analysis was performed according to age, gender, and state. Results During the study period, 13,193 (67.0%) EVARs and 6504 (33.0%) OARs were performed in the Australian private sector. OARs fell from 70.5% (n=567) of AAA repairs in 2000 to 15.7% (n=237) in 2019, while EVARs rose from 29.5% (n=151) to 84.3% (n=808). The frequency of EVAR surpassed OAR in 2004. The overall incidence of AAA repair varied minimally over the time period (range: 4.9–6.5 per 100,000 adults per year). AAA repair was more common in males than females (9.7 vs 1.7 per 100,000 population) and more common in older age groups. There was a 4-fold increase in EVAR among males older than 85 years (12.8–57.4 per 100,000 population), the largest rise of any group. The overall EVAR:OAR ratio increased from 0.4 to 5.4. There were considerable state-based discrepancies. Conclusion The landscape of AAA repair in Australian private sector has drastically changed with a clear preference toward EVAR. EVAR saw increased use across all genders, age groups and states, despite stable rates of AAA surgery. Further research is necessary to compare our findings to national trends in the Australian public sector.

Rural general surgeon confidence with managing vascular emergencies: A national survey

“…Up until 1995, when the RACS Board of Vascular Surgery was established, general surgeons could complete 2 years of specialist vascular surgery training post general surgical training or undertake vascular rotations during their formal general surgery training. Concurrently, the rapid advancement and prevalence of endovascular surgery means general surgical trainees get less exposure to traditional open emergent procedures, including embolectomy and AAA repair 15,16 . This is concerning, as our study has shown that younger and less experienced rural general surgeons, with reduced access to vascular training, have lower levels of confidence performing open vascular surgery.…”

“…Concurrently, the rapid advancement and prevalence of endovascular surgery means general surgical trainees get less exposure to traditional open emergent procedures, including embolectomy and AAA repair. 15,16 This is concerning, as our study has shown that younger and less experienced rural general surgeons, with reduced access to vascular training, have lower levels of confidence performing open vascular surgery. Open vascular surgery, however, may be the only option for time critical emergency cases that present to rural centres.…”

Trends in AAA Repair in Australia Over Twenty Years

“…A similar trend was observed in a study conducted in the Australian private sector, reflecting consistency in surgical decision-making across the public and private sectors in Australia. 5 Comparable transitions to minimally invasive approaches have been noted in the realm of general surgery with the introduction of laparoscopic inguinal hernia repair without an overall increase in the volume of hernia repairs. 12 …”

“… 4 The first commercial EVAR was successfully deployed in Australia in 1993. 5 Since this milestone, Australia has not only been pioneering early adoption of such technology but has also significantly contributed to the innovation in stent graft technology with the first bifurcated graft in 1994 and first fenestrated graft in 1998. 5 …”

Restoring flow to the Aotearoa New Zealand vascular workforce pipeline requires tangible strategic interventions

“…19 Compared to their equivalent in Australia, on average, the salary of AoNZ specialists is 40% less, and the top step on the Te Whatu Ora specialist base salary scale is slightly below the lowest base salary step for a newly qualified Australian specialist. 20 This is in part due to the structure of healthcare reimbursement in Australia, where private insurance can generally cover both emergent and elective surgery pathways and the private sector is the primary provider of surgical services, 21 whereas in AoNZ, acute surgical care is predominantly public. While renumeration is important, workforce retention is also influenced by opportunities for flexible working arrangements, career progression, social benefits (retirement policies and pensions), and conditions that enable reasonable work-life balance.…”